Lingard E A, Berven S, Katz J N
Department of Orthopedic Research, MRB-114a, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
Arthritis Care Res. 2000 Jun;13(3):129-36.
To examine variation in the process of care for total knee arthroplasty (TKA) and to highlight the need for rigorous research into the ideal management of TKA. We hypothesize that variation in the process of care for TKA across and within health care systems is associated with identifiable financial and historical factors.
We compared access to TKA and typical postoperative rehabilitation management in 12 orthopedic centers in the United States (4 centers), United Kingdom (6 centers), and Australia (2 centers). We collected data from two sources: 1) Empirical data on length of stay and discharge management were collected as part of a prospective study of the outcomes of primary TKA for patients with a diagnosis of osteoarthritis; 2) Structured qualitative interviews were conducted at each of the participating centers to collect data on academic status and reimbursement structure, as well as waiting times for orthopedic consultation and TKA surgery once it had been scheduled.
We demonstrated differences in length of acute hospital stay, use of extended care facilities, home physical therapy, and outpatient physical therapy within our cohort of hospitals. The publicly funded hospitals had a significantly longer acute hospital length of stay (mean 11.8 days, SD 7.1) than the private hospitals (mean 6.6 days, SD 4.1; P < 0.0001). Variation in waiting times was associated with the method of surgeon reimbursement and whether the hospital is publicly funded or private. Patients attending private hospitals waited 1-8 weeks for the first consultation and 2-12 weeks for a surgical date after scheduling. In contrast, patients attending publicly funded hospitals waited 4-12 months for a first consultation and 12-18 months for a surgical date after scheduling.
Our observations are consistent with the hypothesis that financial reimbursement schemes influence the management of TKA. Further research needs to be done to quantify effects of varying processes of care on the outcome of TKA surgery across different health care settings. This data would elucidate the optimal management of TKA using objective evidence rather than relying on financial incentives or the preservation of historical practices.
研究全膝关节置换术（TKA）护理过程中的差异，并强调对TKA理想管理方式进行严谨研究的必要性。我们假设，医疗保健系统之间及内部TKA护理过程的差异与可识别的财务和历史因素相关。
我们比较了美国（4个中心）、英国（6个中心）和澳大利亚（2个中心）的12个骨科中心的TKA手术可及性以及典型的术后康复管理情况。我们从两个来源收集数据：1）作为对诊断为骨关节炎的患者进行初次TKA结局的前瞻性研究的一部分，收集住院时间和出院管理的实证数据；2）在每个参与中心进行结构化定性访谈，以收集有关学术地位和报销结构的数据，以及骨科会诊等待时间和TKA手术安排后的等待时间。
我们证明了在我们的医院队列中，急性住院时间、延长护理设施的使用、家庭物理治疗和门诊物理治疗存在差异。公立资助医院的急性住院时间（平均11.8天，标准差7.1）明显长于私立医院（平均6.6天，标准差4.1；P < 0.0001）。等待时间的差异与外科医生的报销方式以及医院是公立资助还是私立有关。在私立医院就诊的患者首次会诊等待1 - 8周，安排手术日期后等待2 - 12周。相比之下，在公立资助医院就诊的患者首次会诊等待4 - 12个月，安排手术日期后等待12 - 18个月。
我们的观察结果与财务报销方案影响TKA管理的假设一致。需要进一步研究以量化不同护理过程对不同医疗保健环境下TKA手术结局的影响。这些数据将以客观证据阐明TKA的最佳管理方式，而不是依赖财务激励或沿袭历史做法。
